Ophthalmology and Optometry Coding Alert

When the federal Food and Drug Administration (FDA) approved verteporfin (Visudyne) this spring for photodynamic therapy (PDT), retinologists were able to start using it on their patients, even though there is no code for the drug or the procedure. By next fall, there may be a specific CPT code for PDT, as well as a HCPCS code for the Visudyne. But if you are providing this service now, how can you bill for it?

The correct way to bill is a combination of 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for injection of the medication, 67220 (destruction of localized lesion of choroid [e.g., choroidal neovascularization], one or more session, photocoagulation [e.g., laser, ocular photodynamic therapy]) for the laser, and J3490 (unclassified drugs) for the medication.

New Code Will Have Lower RVU

Local carriers, however, will make their own decisions on coverage and payment. The Health Care Financing Administration (HCFA) has agreed to issue a notice of coverage to local carriers but carriers dont have to abide by it. What HCFA wants is to arrive at a new code with a lesser RVU than is attached to 67220. The American Academy of Ophthalmology (AAO) is working to develop fair work values. Also, PDT will be removed from the code description of 67220.

Paul Fernandes, billing manager for Long Island Vitreo Retinal Consultants, a practice with six ophthalmologists in N.Y. and one of the specialists participating in the clinical trials for Visudyne, has been billing 67220, 90780 and J3490 since April 4. Weve been paid for PDT by commercial payers, but not by Medicare yet, says Fernandes. Im not banking on getting anything back from Medicare. So far, Medicare has asked for fluorescein angiograms, and one carrier has asked for documentation of visual acuity.

The big problem, according to Fernandes, is the cost of the drug $1,200 per dose. I meet with patients who want this procedure and explain that I have to ask them to sign a waiver in case Medicare wont pay for the drug, he says. When I tell them the cost, they are a bit shocked. But they are signing the waiver. Some practices performing PDT are collecting payment for the Visudyne up front, but Fernandes prefers the waiver approach.

Tip: Check with your carrier. Some Medicare carriers require that the patient must have better than 20/200 visual acuity, corrected, to pay 67220. Note that there is no national policy as of yet, so all requirements are by LMRPs.

67220 vs. 67299

HCFA would prefer providers to use 67299 (unlisted procedure, posterior segment), but there is no rule that you have to. The fact is that the descriptor for 67220 specifies ocular photodynamic therapy. Thats exactly what the Visudyne-laser combination is. Its fine to use 67220 because the code says photodynamic therapy. You are not being fraudulent if you perform photodynamic therapy and you use that code, says Raequell Duran, president of Practice Solutions, a Santa Barbara, Calif.-based ophthalmology coding, reimbursement and compliance consulting firm. The new code being developed for CPT 2001 will be specifically for PDT, and it will include the infusion.

Consider the Drug Cost

But its the drug that is the big question mark, as Fernandes indicates. Whether you can decide to offer PDT, you need to think about the drug costs, he warns. This isnt a one-shot deal, he says. Our doctors think this will require more than one treatment. And some patients are presenting a special problem because they already received one or more treatments for free under the clinical trials.

One patient, for example, came to Fernandes practice because he had two PDT treatments in Florida in clinical trials but needed another. This should not be a problem for payment because the new doctor has a different provider number and the laser would not be included in the global package for the original doctor. But for a subsequent treatment done within the 90-day post-op period by the same physician who performed the preceding 67220, the doctor couldnt get paid for the laser again.

Ophthalmology coding sources say that the new code for PDT probably will not be valued with any postoperative visits, and therefore would not have a postoperative period. This means there will be no global period and ophthalmologists will have to bill for the postoperative office visits.

Tip: You can enhance the chance that the local Medicare carrier will pay for the drug by attaching a copy of the invoice showing the cost of the drug and summaries of the research showing the good results from this form of treatment. Otherwise the carrier does not have enough information to pay appropriately even if they are willing.

What Are Visudyne and PDT? Visudyne is the drug injected into the eye in what is called PDT, or photodynamic therapy. In combination with the laser, the drug usually stops the degeneration of the macula in the wet form of age-related macular degeneration, or AMD (362.5x). PDT works as well as or better than traditional treatment for patients with AMD, clinical research shows. And in patients whose degeneration was in the center of the fovea the part of the retina that produces the sharpest vision there was no treatment available at all until PDT.